4 cases of pelvic mass are discussed .Adnexal mass invilves masses arisinf from ovary,fallopian tube,uterus,bowel and some miscellenious masses.USG is used to detect its size and the origin.Histopathological findings are diagnostic.
4 cases of pelvic mass are discussed .Adnexal mass invilves masses arisinf from ovary,fallopian tube,uterus,bowel and some miscellenious masses.USG is used to detect its size and the origin.Histopathological findings are diagnostic.
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
Sharp injuries and needle stick post exposure prophylaxis [compatibility mode]drnahla
Infection Control Guidelines for Sharp injuries and needle stick post exposure prophylaxis
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
Sharp injuries and needle stick post exposure prophylaxis [compatibility mode]drnahla
Infection Control Guidelines for Sharp injuries and needle stick post exposure prophylaxis
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
10. Estimated Per‐Act Risk of Acquisition of HIV
by Exposure Route *
Exposure route Risk /10000 exposures %
to infected source
Blood transfusion (1unit) 9250 92.5
Mother-to-child transmission 1500-3000 15-30
Receptive anal intercourse 100-3000 1-30
Insertive anal intercourse 10-1000 0.1-10
Receptive penile-vaginal intercourse 10-1000 0.1-10
Insertive penile-vaginal intercourse 10-100 0.10-1.0
Receptive penile-oral intercourse ** 0 –4 0.00-0.04 (E+>E-)
Insertive penile-oral intercourse** 0-0.5 0.00-0.005 (E+>E-)
Oro-vaginal intercourse *** F-M , M-F NA, but not zero NA, but not zero
Oro-vaginal intercourse *** F-F NA, but not zero NA, but not zero
Needle-sharing IDU 67-80 0.67-0.80
Needle stick (percutaneous exposure)) 30 0.3
Mucous membrane exposure 9 0.09
* Estimates of risk for sexual transmission .assume no condom use. ** Fellatio *** Cunnilingus
Landovitz R. NEJM 2009;361:1768. Baggaley R. Int J Epi 2008;37:1255 US DHHS MMWR 2005;54(No. RR‐2):1‐19.
Roland E J Infect dis 2004;190:598 Varghese B. Sex Trans Dis 2002;29:38
11. Risk of HIV Occupational Transmission
by Type of Exposure
Type of exposure Risk per blood exposure
Estimate 95% CI
Percutaneous 0.3 0.2-0.5
Mucocutaneous 0.09 0.006-0.5
Non-intact skin < 0.09 NA
- No seroconversion after intact skin exposure
- Risk unknown due to fluids/tissues other than blood
Bell Henderson DK. AIDS therapy 2003:327 Bell DM. Am J Med 1997;102 (suppl 5B) 9-15
MMWR 2005; 54: No. RR-9
12. Risk Factors for HIV Occupational Transmission
CDC case‐control study
Risk Factor Adjusted OR* (95% CI)
♦Deep injury 15.0 (6.0-41.0)
♦Visible blood on device 6.2 (2.2-21.0)
♦Procedure involving needle 4.3 (1.7-12.0)
placed in artery or vein
♦Terminal illness in source 5.6 (2.0-16.0)
patient
♦ Zidovudine PEP 0.19 (0.06-0.52)
* p < 0.01 for all
Cardo DM et al. NEJM 1997;337:1485‐90
13. Estimated Pathogen‐Specific Seroconversion Rate
Per Exposure for Occupational Needlestick Injury
37‐62
23‐37
0.2‐0.5 0‐7
Occupational Infection Risk
HBV : HCV : HIV ~ 30: 3: 0.3 or ~ 100 : 10 :1
1. MMWR 2005; 54 (No. RR‐09): 1‐24.
2. MMWR. 2001; 50 (No. RR‐11): 1‐42.
3. Gerberding J . N Engl J Med 2003;348:826‐33 4. Henderson D. Clin Microbiol Rev 2003;16:546‐68.
14. Risk Factors for HCV Transmission to HCWs after
Percutaneous Exposure to HCV‐Infected Body Fluids,
A European case‐Control Study
Variable Adjusted OR (95% CI)* p‐value
Device involved in exposure
Suture needle or other sharp object 1.0
Hollow‐bore needle
Not in vein or artery 10.6 (0.9‐128.4) .063
In vein or artery 100.7 (7.9‐1365.7) .0005
Severity of injury
Superficial 1.0
Moderate 47.7 (2.3‐974.1) .01
Deep 155.2 (7.1‐3417.2) .001
Gender of HCW
Female 1.0
Male 3.1 (1.0‐10.0) .056
*Multivariate conditional logistic regression analysis Yazdanpanah Y. CID 2005;41: 1423‐30.
16. Relative Infectivity of HBV, HCV, HIV
HBV HCV HIV
Copies/mL 108-9 105 103
Environmental stability ++++ ++ -
Infectious after drying
at room temperature >7 days >16 h 0
Sources: Bond Lancet 1981; Krawczynski Hepatology 2003
17. Risk of HIV Sexual Transmission
• Difficult to quantify
• Wide range reported for the risks of per contact
transmission derived from observational studies
which are influenced by
: Route and type of sexual intercourse
: Ejaculation/No ejaculation
: +/- concomitant GUDs
: +/- genital trauma
: +/- cervical or anal dysplasia
: Circumcision status
: HIV viral load in the genital compartment
: Degree of HIV virulence
Powers K. Lancet Infect Dis 2008;8:553-63.
Boily M. lancet Infect Dis 2009;9:118-29.
18. Relative Efficiency of HBV, HCV, HIV
Transmission by Type of Exposure
Type of exposure Efficiency of transmission
to infected source HBV HCV HIV
Transfusion ++++ ++++ ++++
Injecting drug use ++++ ++++ ++++
Unsafe injections +++ +++ +
Needlestick +++ + <+
Sexual +++ + +++
Perinatal ++++ ++ +++
Non-intact skin ++ +/- +/-
Intact skin - - -
21. Route of Risk of exposure when Mechanism of exposure
exposure source person HIV +ve
Percutaneous ∼ 1/300 episodes (0.03%) Larger gauge hollow bore
needle > solid needle or
instrument
Mucous ∼ 1/1000 episodes (0.09%) Large volume > small
membrane volume
Cutaneous < 1/1000 episodes (0.09%) Must involve compromised
skin integrity
• Blood-borne pathogens CANNOT transmit through intact skin
• Saliva, urine, feces, respiratory secretions, and gastric fluid that are not
bloody CANNOT transmit HIV
• If the biter got blood in the mouth, the biter has sustained a mucous
membrane exposure
If the biter’s saliva has blood in it , the bitten person has sustained
a percutaneous exposure
22. - Anti-HIV (rapid anti-HIV preferred, ), HBsAg , anti-HCV
- If source person’s anti-HIV is +ve confirmatory test and proceed
with PEP
-If source has known HIV infection but current or recent VL is not known,
send HIV VL.
: Window period for HIV: “…no case of occupational HIV transmission
involving an exposure source during the window period has been
reported in US…”
: New generarion anti-HIV testing ---- combo test
23. ‐ Initiate PEP vs No PEP ------ Guidelines
- If PEP is indicated/considered, first dose should be given ASAP
Optimal time to start PEP is within hours of exposure, rather than days
Outer limit of opportunity to start PEP 48-72 hours
: Do not wait for baseline test results to make PEP decision unless results
of a rapid anti-HIV test on source person will be available within an hour
or two
: “ Found needle” scenario – there’ve never been any documented cases
of HIV transmission from a “found needle” outside of health care setting
: Pregnancy is not a contraindication for PEP
: PEP can always be stopped if new information changes the assessment
1. MMWR Recomm Rep. 2005 , 30;54(RR‐9):1‐17
2. European AIDS Clinical Society Guidelines 2009
25. See the guidelines
: For a given exposure, all of the details needed to choose between
basic vs expanded regimen are not easily available
: When in doubt overnight (eg., ER) start with expanded regimen
: If source person is HIV infected and taking ARVs , start an
expanded regimen
: If source person is anti‐HIV +ve or HIV‐infected and is not taking
ARVs , assume high viral load, and begin expanded regimen
: If source person is of unknown HIV serostatus, consider
a basic regimen (if high risk sources ;eg . IVDUs, CSWs; may
consider expanded regimen)
http:// www.ucsf.edu/hivcnt
27. ‐ Basic: Truvada (TDF +FTC) or
Combivir/Zilavir (ZDV + 3TC)
‐ Expanded : Basic plus Kaletra (LPV/r) or Reyataz (ATV/r)
: Truvada is generally better tolerated and easier to take than
combivir, but either is acceptable
: Combivir/Zilavir is preferred if the exposed HCW is pregnant or if
concern for renal insufficiency
: NNRTI is not a prefered regimen due to
‐ EFV has ADR of dizziness, vertigo , rash ‐‐‐mimicking AHI , C/I
in 1st trimester pregnancy
‐ NVP ADR particularly rash,hepatitis
: TDF + 3TC +ZDV or ZDV+3TC+TDF has been recommended by
some experts*
*New York State Department of Health AIDS Institute: www.hivguidelines.org
28. Recommended PEP Regimens
BASIC REGIMENS EXPANDED REGIMENS
Preferred drugs Basic regimens plus a
- ZDV + 3TC third agent
- TDF + 3TC or PI
Alternative drugs - LPV/r - ATV/r
- d4T + 3TC - IDV/r - SQV/r
- ddI + 3TC - NFV or
NNRTI
HIV infected source with - EFV or
suspected drug resistance
II
- RAL or
EI
MMWR 2005;54(No. RR‐9) 1‐19.
Mechai et al. J Med Virol 2008:80:9‐10 - MVC
Siegel et al. AIDS 2008;22:2252‐53.
Duration – 28 days
29. Duration of HIV PEP
How Long Should PEP be Administered?
100
3 days PEP
• N = 24 macaques 90
80
inoculated with SIV
10 days PEP
70
intravenously 28 days PEP
60
• PMPA for PEP initiated 50
50
24 hours post-inoculation 40
• PEP administered for 30 25
20
3, 10, or 28 days 10
0
0
seroconversion rate (%)
Duration of PEP = 28 days
Tsai C-C et al. J Virol 1998;72:4265-73
30. Evidence of Efficacy of HIV PEP
• Animal models: high level of protection when started
within 24 hours 1
• OR = 0.19 for zidovudine use in case-control study 2
• Two drugs, three drugs:
– No direct evidence that more effective than
1 drug
– Cases of seroconversion despite 3-drug PEP
imply efficacy less than 100% 3,4
Standard/universal precaution is still the most important!
1. Tsai C-C et al. J Virol 1998;72:4265-73 2. Cardo DM et al. NEJM 1997;337:1485-90
3. Jochinsen EM et al. Arch Int Med 1999;159:2361-3. 4. MMWR June 29, 2001 / 50(RR11);1-42
31. Follow-up of HCP exposed to known or
suspected HIV-positive sources
• Exposed HCP should be advised to use precautions to
prevent secondary transmission, especially during the first
6–12 weeks post-exposure
• If PEP is prescribed, HCP should be informed regarding:
– need for monitoring
– possible drug interactions
– the need for adherence to PEP regimens
• Consider re-evaluation of exposed HCP 72 hours post-
exposure, especially after additional information about the
exposure or source becomes available
CDC, US DHHS. MMWR 2005;54(No. RR-9).1-51.
32. Follow-up of HCP exposed to known or
suspected HIV-positive sources (cont)
• HIV Ab testing for 6 months post-exposure
(e.g., at 6 weeks, 3 months, 6 months)
• Extended HIV Ab testing at 12 months is recommended
if health care worker contracts HCV from a source
patient co-infected with HIV and HCV
• P 24 Ag and HIV RNA testing are not recommended
unless primary HIV infection (PHI) suspected
• Symptoms and signs of primary HIV infection should be
informed to exposed HCP
CDC, US DHHS. MMWR 2005;54(No. RR-9).1-51.
35. Post-Exposure Follow Up for
HCV Infection
New York State Department of Health AIDS Institute: www.hivguidelines.org
36.
37. 1. Immunologic milieu of a mucosal exposure, especially in
genital exposure, differs from that in a percutaneous
exposure
2. HIV viral load and resistance patterns of virus in genital
secretions differ from those in blood
3. Repeated exposures are more common in sexual exposure
n PEP “ morning after pill “
38. 4. Source testing is frequently impossible
source HIV serostatus is not known
5. In rape victim, more physical and psychic trauma are
frequently encountered
6. Adherence to nPEP and follow up after nPEP, particularly
In
rape victim, are usually poorer than occupational PEP
39. DHHS Recommendations for ARV Postexposure
Prophylaxis for Nonoccupational Exposure to HIV
Smith DK. Recommendations from the U.S. DHHS. MMWR 2005;54(No. RR‐2):1‐20.
40. Assessing Risk for HIV Exposure
Substantial Risk Negligible Risk
for HIV Exposure for HIV Exposure
Exposure of: Exposure of:
• vagina, rectum, eye, mouth or • vagina, rectum, eye, mouth or
other mucous membrane, other mucous membrane, intact
nonintact skin, or percutaneous or nonintact skin, or percutaneous
contact contact
With: With:
• blood, semen, vaginal • urine, nasal secretions, saliva,
secretions, rectal secretions, sweat, or tears if not visibly
breast milk, or any body fluid that contaminated with blood
is visibly contaminated with blood
Regardless of the known or
suspected HIV status
of the source
RAPE Risk of transmission
48. Consideration of nPEP According to the Type of Risk Exposure
Type of Exposures That Do Not Type of Exposures That Should
Warrant nPEP Prompt Consideration of nPEP
Kissing Unprotected receptive and insertive vaginal
or anal intercourse with a source that is
HIV-infected or at risk for HIV infection
Oral-to-oral contact without mucosal damage Unprotected receptive penile-oral contact
(mouth-to-mouth resuscitation) with ejaculation with a source that is
HIV-infected or at risk for HIV infection
Human bites not involving blood Oral-vaginal contact with blood exposure
Exposure to needles or sharps not in contact Needle sharing with a source known to be
with an HIV-infected or at-risk person HIV-infected or at risk for HIV infection
Mutual masturbation without skin breakdown Injuries with exposure to blood from a
source known to be HIV-infected or at risk for
HIV infection (including needlesticks, human
bites, accidents)
Oral-anal contact
Receptive penile-oral contact without
ejaculation
Insertive penile-oral contact
Oral-vaginal contact without blood exposure
HIV Prophylaxis Following Non-Occupational Exposure Including Sexual Assault. JHU 2010 . http://hivguidelines.org
